Eleanor Clarke Slagle Lectureship Nomination Form

ELEANOR CLARKE SLAGLE LECTURESHIP NOMINATION FORM

Description

An academic honor established as a memorial to Eleanor Clarke Slagle, one of the outstanding pioneers in the profession of occupational therapy.

Purpose

· TO HONOR a member of the Association who has creatively contributed to the development of the body of knowledge of the profession through research, education, and/or clinical practice.

· TO ACKNOWLEDGE the advancement of theory, standards, and improved methods that enhance service to consumers and promote public awareness and understanding of occupational therapy.

· TO GIVE outstanding occupational therapists and occupational therapy assistants a distinctive opportunity to share their knowledge and experience with the membership.

· TO ENABLE members to benefit from new knowledge, innovative perspectives, and significant developments in the profession.

Minimal Requirements

1. The nominee shall be an occupational therapist or an occupational therapy assistant and a member in good standing of the Association at the time of the nomination and presentation of the award.

2. The nominee shall have made a significant contribution to the body of knowledge of the profession. This will be manifest in the development or refinement of professional theory and/or techniques that enhance clinical or educational practice and/or involvement in outstanding research activities.

3. The nominee shall have shared his or her knowledge and inspired others through written publications and oral presentations.

4. Both scholarly contribution and volunteer organizational leadership will be considered.

Specific Information Regarding Award

1. The individual selected for this award shall be notified by the President of the Association and shall, in turn, convey his or her acceptance before public announcement.

2. Recipients of this award will present The Slagle Lecture during the AOTA Annual Conference & Expo in the following year.

3. The awardee shall be announced by the President of the Association, or the previous Slagle lecturer, at the Annual Conference & Expo the year before the lecture is to be presented.

4. An inscribed plaque, highlighting the awardee’s contributions and the year selected, and a monetary gift shall be presented by the President of the Association at the Annual Conference & Expo the year the lecture is given.

5. If the awardee is not a member of the Roster of Fellows or Roster of Honor, he or she will be designated as such and will be presented with the appropriate certificate at the time the Eleanor Clarke Slagle Lectureship Award is announced.

6. The name of the awardee, as well as the text of the lecture, shall be published in the American Journal of Occupational Therapy (AJOT®.).

7. The name of the awardee and the year selected shall be inscribed on the Eleanor Clarke Slagle Lectureship plaque located in the Association Headquarters.

INSTRUCTIONS:

Please complete this form for each nomination. All information must be typed.

Note: If notification is to be sent to a university address, please be sure to include as much detailed information on the address as possible, (i.e., room, division, building, mail stop, campus box). Please be aware that notifications may be sent during typical university breaks.

1. NOMINEE

Name & Credentials
Title
Address
City/State/Zip
Telephone (Office) / Telephone (Home)
E-mail
AOTA Member ID # / Expiration Date
Number of years activity in occupational therapy:

2. PRIMARY NOMINATOR

Name & Credentials
Title
Address
City/State/Zip
Telephone (Office) / Telephone (Home)
E-mail (Office)
E-mail (Home)
AOTA Member ID # / Expiration Date

3. SEVEN-WORD STATEMENT: This statement needs to directly reflect the content of the Narrative and capture the significant impact of the individual’s contributions. Please note that this is the statement that will appear on the actual award. The Recognitions Committee reserves the right to modify statements.

4. NARRATIVE:

· Submit a narrative that describes how the individual’s significant contributions justify his or her receipt of this award. Please refer to the purpose and criteria of the specific award in your discussion of his or her eligibility.

· The purpose of the narrative is to augment or explain—not repeat—the information included in section 5: Relevant Experience.

· Do not exceed eight (8) double-spaced pages using 12-point font.

· Please do NOT send letters of support as they are not considered in the review process.

· The narrative will be included in the scoring process.

5. RELEVANT EXPERIENCE: SELECTION CRITERIA.

All information must be typed and outlined according to the following selection criteria. Space will expand to accommodate response. Additional rows may be added. The format may be re-created as a Word document. Please do not send or substitute the nominee's curriculum vitae (CV).

EDUCATION

Date of Graduation
(MM/DD/YYYY) / Degree/Area / Institution

PAID PROFESSIONAL WORK EXPERIENCE

Dates / Post/Title / Institution/Facility

PROFESSIONAL RECOGNITION (Awards, Citations, etc)

Dates / National/State/Local
(please indicate) / Award

COMMUNICATION—WRITTEN

· Please only include work that is published.

· List funded grants only, and please include the funding amount and role (e.g. PI).

Dates / Title / Publisher / Type of Publication

COMMUNICATION—ORAL

· Please include first offering of presentation only.

· If co-presenting with others, please identify the specific amount of speaking time.

· Include only completed presentations.

Date(s) of Event / Actual Length of Presentation / Title / Location / Type of Presentation

COMMUNICATION—AUDIOVISUALS, WEB-RELATED

Date / Title & Procurement Information / Type of A/V, Web Materials Produced / Distribution Source

VOLUNTEER SERVICE TO ASSOCIATION AND NON–OT HEALTH ORGANIZATIONS (i.e., AOTA, AOTF, ACOTE, AOTPAC, RA, AJOT)

National: Please identify each unique volunteer experience and position separately and in chronological order.

Specific Dates of Service (Mo/Yr)
(e.g., 1/23/05 – 9/18/06) / Total Years/Months (e.g., 1 yr 8 mos.) / Name of Organization & Position Held / Position Type
A / B / C

State: Please identify each unique volunteer experience and position separately and in chronological order.

Specific Dates of Service (Mo/Yr)
(e.g., 1/23/05 – 9/18/06) / Total Years/Months (e.g., 1 yr 8 mos.) / Name of Organization & Position Held / Position Type
A / B / C

Local: Please identify each unique volunteer experience and position separately and in chronological order.

Specific Dates of Service (Mo/Yr)
(e.g., 1/23/05 – 9/18/06) / Total Years/Months (e.g., 1 yr 8 mos.) / Name of Organization & Position Held / Position Type
A / B / C

KEY: Position Types

A. Officer—(i.e., President, Vice President, Secretary, Treasurer, Speaker, Vice Speaker, Recorder)

B. Major Organization—Advisory or Board Member, Committee/Commission Task Force Chairperson, AOTA Representative or Alternate Representative, SIS Chairperson, Grant Reviewer, Licensure Board Chairperson, Journal Editor, Caucus Chairperson, ACOTE

C. Committee/Commission Task Force Member, Liaison, Licensure Board Member, Consultant/Advisor, Editorial Board Member, Conference Paper Reviewer, Accreditation Evaluator

6. VERIFICATION AND PHOTO:

· All nominations must include a signed verification form and photo.

· Include current credentials and name as desired for publication.

· Include pronunciation of name for use of announcer during Awards Ceremony.

· Be sure that photo is in digital jpeg format and in “print” resolution. (Web resolution cannot be accepted).

· Head shots in professional dress are most desirable for publication. If this is not possible, crop unwanted background.

7. SUBMISSION GUIDELINES

· Questions regarding this award can be directed to prior to the nomination deadline.

· If the required FORMAT is not followed, the nomination will NOT BE SCORED. Do NOT include a curriculum vitae (CV).

· Submissions will only be accepted electronically. Please send the nomination form and the narrative statement NO LATER THAN September 12, 2013, to .

Statement of Authenticity:

I have read the instructions and clarifying information provided me in this document and attest to the accuracy of the information I have included in this nomination form and the accompanying narrative.

Signature of Nominator Date

NOTE: My electronic (typed) signature on this document constitutes my legal signature in accordance with 21 CFR Part 11: Electronic Records; Electronic Signatures Act.